Provider Demographics
NPI:1104337005
Name:RED CANYON WELLNESS
Entity type:Organization
Organization Name:RED CANYON WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:VIEJO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-994-4606
Mailing Address - Street 1:9999 S MINGO RD STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5144
Mailing Address - Country:US
Mailing Address - Phone:918-994-4606
Mailing Address - Fax:918-994-4607
Practice Address - Street 1:9999 SOUTH MINGO RD., STE. B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7413
Practice Address - Country:US
Practice Address - Phone:918-994-4606
Practice Address - Fax:918-994-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4091111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty